Our Dental Suite is designed for efficient administration of government and commercial dental benefit programs. The system comes preconfigured with dental-specific terminology, procedure codes, business rules, real-time dashboards and on-demand reports, all based on dental industry best practices. It can easily be scaled up or down to meet your unique membership and claim volume needs.
The Enterprise System Dental Suite’s comprehensive set of administrative functions includes:
- Enrollment and eligibility
- Fee schedule management
- Flexible reimbursement methods
- Benefit plan design & maintenance
- Claim data entry
- Claim editing, adjudication and payment
- Customer service
- Provider network management
- Premium billing
Choose From a Full Spectrum of Features
With the Enterprise System Dental Suite, you can continue to use the features in your existing system that work well for you. Choose the Dental Suite functionality that you need, and we will work with you to integrate seamlessly with your existing system.
Self-service portals offer easy access to real-time data drawn directly from the Enterprise System. For example, dentists can quickly check patient eligibility for services, submit claims, and review remittance reports as soon as claims are paid. Web portals help minimize paper flow and calls to support staff, and help providers focus on quality of care.
Real-time dashboards provide instant access to up-to-the-minute data as well as insight into trends over time. Use dashboards to analyze:
- Claim and authorization volumes, history, and trends
- Claim and authorization utilization statistics and summaries
- Enrollment statistics and trends
- Premium billing statistics and trends
- Provider reimbursement paid claim dollars and trends
- Provider/patient distributions
- Provider profiling
- IBNR calculations
- Benefit loss ratios and trends
- Self-funded account paid claim dollars and claim cost per subscriber summaries and trends
- Customer service call volumes
The Enterprise System is designed to support paperless workflows with its web-based architecture, built-in document management system and fully integrated self-service web portals.
- Data file imports. The Enterprise System can import and process electronic data file loads in HIPAA-compliant version 5010 transaction set format and in its own proprietary file import format. Automated processing rules can be easily defined and managed through the user interface. Detailed Companion Guides and file format layouts are just a click away in the Online Help Reference Library.
- Integrated document management system. The integrated document management system can minimize or eliminate third-party document storage and retrieval fees. Electronic documents in nearly any standard file format can be attached and retrieved for instant online review throughout the system. For example, electronic health records and x-rays can be attached and included with a patient’s comprehensive claim history. Selected documents can also be made available through self-service web portals.
Flexible Reimbursement Methods
The Dental Suite enables healthcare payers to leverage flexible reimbursement plans based on a variety of reimbursement methods and flexible calculation rules used to determine costs for each service performed.
Tightly Integrated Authorizations & Claims
The Enterprise System Dental Suite features tight integration between authorizations and claims:
- Authorization/claim reviews, including prior reviews for medical necessity, can be performed before claims are processed for payment. During claim processing, additional business rules can perform post reviews.
- Requirements for supporting documentation can be set up and enforced through the system, with automatic administrative denials when required documentation is not submitted.
- Authorizations are logged and automatically linked with associated claims. As claims are processed, authorizations are automatically consumed (decremented).
- Authorization and claim history, statistics, and trends are instantly available in real-time dashboards.
Customer Service Tools
The Enterprise System Dental Suite supports fast, accurate responses to inquiries from members and providers. Call center staff have the resources they need, right at their fingertips, to:
- Research and answer questions about benefits, claims, pre-treatment estimates, and eligibility.
- Find a dentist or specialist for a member and provide office hours, languages, and driving instructions.
- Review supporting documentation attached to claims.
- Verify PHI access permissions.
- Assign a follow-up call to another staff person or department and send an email alert.
- Create a follow-up work queue.
- Handle requests for out-of-network providers.
- Reset web portal passwords and unlock accounts.
- Generate comprehensive call history and provider request reports.
The Dental Suite also features a complete call history for every logged communication and follow-up response, as well as detailed on-demand reports and dashboards about call history trends and performance statistics.
Focused Cost-Containment Features & Utilization Management
The flexibility of the Enterprise System Dental Suite allows each healthcare payer to chart its own path toward containing costs and managing utilization without sacrificing provider and member satisfaction. Dental Suite tools for managing costs and utilization include:
- Customizable dental edits and business rules. The Enterprise System uses these rules to identify and automatically approve or deny services for administrative reasons where appropriate, and to trigger exceptions for review during claim and authorization processing cycles.
- Clinical algorithms applied at the individual plan level, based on historical analysis and profiling results. These clinical guidelines can then be used by dental review specialists and dental consultants to ensure consistent authorization determinations. The guidelines are available to providers through a web portal, so participating dentists can follow the decision matrix and understand the logic behind authorization decisions.
- Dental reviewer efficiency monitoring. The efficiency and results of each dental reviewer can be monitored and analyzed by a number of parameters, including turnaround times, number of approvals, number of denials, reviews by code, reviewer denial rates, and savings amounts. A consistent approach to authorization determinations promotes clarity and transparency for providers, which in turn reduces provider participation costs and client administrative costs.
- Provider profiling and data analysis reporting. The Enterprise System Dental Suite includes a sophisticated provider profiling tool to assess practice patterns and identify outliers. The system provides access to hundreds of customizable data analysis reports to help manage benefit costs and identify areas of potential utilization management review.